Received: 7 July 2020 Revised: 21 August 2020 Accepted: 5 September 2020

DOI: 10.1002/jdd.12423

ORIGINAL ARTICLE

Nigerian undergraduate dental students’ knowledge,

perception, and attitude to COVID-19 and infection
control practices

Kehinde Adesola Umeizudike BDS, MPH, FMCDS1 Ikenna Gerald Isiekwe BDS,
MPH, FMCDS2 Adeyemi Dada Fadeju BChD, FWACS3
Bolanle Oyeyemi Akinboboye BDS, MSc, FWACS4
Emmanuel Temitope Aladenika BSc, BDS5

1Department of Preventive Dentistry,

Faculty of Dental Sciences, College of
Medicine, University of Lagos/Lagos
University Teaching Hospital, Idi-Araba,
Lagos, Nigeria
2Department of Child Dental Health,
Faculty of Dental Sciences, College of
Medicine, University of Lagos/Lagos
University Teaching Hospital, Idi-Araba,
Lagos, Nigeria
3 Department of Child Dental Health,
Faculty of Dentistry, Obafemi Awolowo
University/Obafemi Awolowo University
Teaching Hospital Complex, Ile-Ife, Osun
State, Nigeria
4Department of Restorative Dentistry,
Faculty of Dental Sciences, College of
Medicine, University of Lagos/Lagos
University Teaching Hospital, Idi-Araba,
Lagos, Nigeria
5Department of Preventive Dentistry,
Lagos University Teaching Hospital,
Idi-Araba, Lagos, Nigeria
Correspondence
Dr. Kehinde Adesola Umeizudike, BDS,
MPH, FMCDS, Associate Professor &
Consultant Periodontologist, Department
of Preventive Dentistry, Faculty of Dental
Sciences, College of Medicine, University
of Lagos, P.M.B. 12003 Idi-Araba, Lagos,
Nigeria.
Email: kumeiz09@gmail.com
Abstract
Purpose/objectives: The current coronavirus disease 19 (COVID-19) pandemic
has affected most countries. Infection, Prevention, and Control training is impor-
tant in mitigating the spread of COVID-19. The closure of universities by the
Nigerian government has hampered academic activities of dental students. Our
objectives were to assess the knowledge, perception, and attitude of undergrad-
uate dental students in Nigeria to the COVID-19 pandemic and infection control
practices.
Methods: This was a cross-sectional study of undergraduate clinical dental
students from the dental schools in Nigeria. Self-administered questionnaires
were distributed to participants using an online data collection platform. Cor-
rect responses to the 45-item questionnaire on COVID-19 knowledge were scored
to determine their knowledge level. A Likert scale of 1-5 was used to assess the
13-item perception and attitude questions. The level of significance was set at
P values ≤ 0.05.
Results: A total of 102 undergraduate clinical dental students participated in the
study. Males represented 54.9%, and mean age was 25.3 ± 2.4 years. Fifty per-
cent of the students had adequate knowledge of COVID-19. Final-year students
(58.1%) demonstrated more adequate knowledge of COVID-19 than penultimate-
year students (28.6%, P = 0.008). Most (95.1%) respondents had positive attitudes
towards infection control practices against COVID-19.
Conclusion: Although the clinical dental students had a positive attitude to
infection control practices against COVID-19, the overall knowledge of COVID-19
was barely adequate. Guidelines on COVID-19 from reputable health authorities
should be reviewed by dental school authorities and disseminated to the students
to suit their clinical practice.

KEYWORDS
attitude, COVID-19, knowledge, Nigeria, undergraduate dental students

J Dent Educ. 2020;1–10. wileyonlinelibrary.com/journal/jdd © 2020 American Dental Education Association 1

2 UMEIZUDIKE et al.
1 INTRODUCTION
The new coronavirus infection was first identified in a clus-
ter of patients admitted into hospitals for suspected pneu-
monia of an unknown cause, later linked to a seafood and
wet animal market in Wuhan city, Hubei Province, China,
in December 2019.1 This coronavirus has been identified as
the severe acute respiratory syndrome coronavirus (SARS-
CoV-2).2 This infection was named the novel coronavirus
disease 19 (COVID-19) on February 11, 2020 by the WHO.3
As the disease began to spread rapidly across several coun-
tries, the COVID-19 outbreak was declared a global pan-
demic by the WHO on March 11, 2020.4 Since the initial
cases, COVID-19 has affected more than 27 million people
globally with over 880,000 deaths in about 216 countries
and territories3 as of September 7, 2020, thus posing a seri-
ous and alarming public health concern.
Since the index confirmed case in Nigeria on February
th
27 , 2020, the number of confirmed cases have risen to
55,160 with 1061 COVID-19 related deaths, as of September
8, 2020.5 The increase in the number of confirmed cases
led the federal government of Nigeria (FGN) in March
2020 to effect the immediate closure of all educational
institutions including universities, airports, land borders,
and religious and recreational centers, amongst others, as
major efforts to curb the spread of the infection.5 The Nige-
ria Centre for Disease Control (NCDC) in partnership with
the Ministry of Health and State governments has been
actively involved in contact tracing, testing, isolation, and
treatment of COVID-19 cases in Nigeria.5 Numerous cam-
paigns have been embarked upon through the media for
preventive measures such as hand hygiene, respiratory eti-
quette, social/physical distancing, noncontact temperature
screening, and facemask wearing in public places to limit
the spread of the disease.
The COVID-19 pandemic has also affected dental train-
ing schools and dental clinics all over the world, with ini-
tial restrictions to emergency and urgent dental care.6–8
The Nigerian Dental Association also issued some guide-
lines on COVID-19 protocol for dental clinics in Nigeria to
postpone elective procedures in April, 2020.9 This is due
to the reported high risk of infection amongst dental pro-
fessionals as a result of the large amounts of aerosols gen-
erating procedures and their close proximity to patients in
confined treatment offices/clinic. The coronavirus has also
been found in the saliva of infected persons,10 and shown
to survive in aerosols for hours and on surfaces for days.11
The closure of universities by the FGN in a bid to limit
the spread of COVID-19, has hampered the academic activ-
ities of dental schools and clinical training of dental stu-
dents in Nigeria. The pandemic also affected the training
activities of dental students in countries such as China12
and Canada.13 Dental students in China had to continue
learning online after the Chinese Spring Festival and were
told not to return to school until further notification at the
onset of the pandemic.12 Also in Canada, many third- and
fourth-year undergraduate dental students within a den-
tal geriatric module in the University of British Columbia,
Vancouver, were unable to participate in the clinical geri-
atric care activities due to the COVID-19 pandemic.13 The
ongoing industrial strike action embarked by the Aca-
demic Staff Union of Universities in Nigeria has further
worsened the situation as all forms of training in federal
universities have been grossly affected. The impact on the
effective training of dental students in Nigerian universi-
ties is likely to be severe, further worsened by the highly
contagious nature of the COVID-19 infection in clinic set-
tings by the time dental schools in Nigeria reopen.
Previous studies among Nigerian dental students had
highlighted the importance of feedbacks from students on
the factors that affecting their training and how these could
be overcome.14–16 The COVID-19 pandemic presents with a
new range of challenges for undergraduate dental training,
not only in Nigeria, but worldwide which include infec-
tion control practices in the clinic. Understanding these
challenges will assist and guide dental faculties in assisting
dental students through these very difficult times. The aim
of this study was therefore to assess the knowledge, percep-
tion and attitude to the COVID-19 pandemic and infection
control practices among undergraduate clinical dental stu-
dents in Nigeria.
2 MATERIALS AND METHODS
Ethical approval for this study was obtained from the
Health Research Ethics Committee of the Lagos University
Teaching Hospital. The Ethical approval number for the
study is LUTHHREC/EREV/0420/12. This was a descrip-
tive cross-sectional study in which the study population
was made up of undergraduate clinical dental students in
their penultimate (Year 5) and final years (Year 6) from
9 out of the 12 accredited dental schools in Nigeria. The
estimated population of undergraduate clinical dental stu-
dents in Nigeria is 400, as they constitute a smaller seg-
ment of all undergraduate dental students in the country.
The sample size of the participants for the study was deter-
mined to be 102 using a confidence level of 98% within a
10% margin of error. Informed consent was obtained from
all respondents in the study. Self-administered question-
naires were distributed and sent out repeatedly to partic-
ipants using an online data collection platform (Google
forms), between April 30 and June 6, 2020 using a purpo-
sive sampling technique. The respondents were accessed
through their WhatsApp general dental students’ platform
and direct WhatsApp messages. The questionnaire had
UMEIZUDIKE et al.
3 sections. Section 1 documented the participants’ sociode-
mographic characteristics while section 2 recorded partic-
ipants’ knowledge of COVID-19. Correct responses were
assigned 1 point while incorrect answers were assigned 0.
Forty-five (n = 45) questions were used to assess the stu-
dents’ knowledge of COVID-19. The total knowledge score
was derived based on the total sum of correct responses
and converted to percentage scores. The level of knowledge
of COVID-19 was categorized into 2: adequate and inad-
equate, using a cut off value of 60% considering the fact
that COVID-19 is still a novel disease. The third section
appraised their perception and attitude towards infection
control practices in the dental clinic using 13 questions.
Participants’ attitudes were assessed using a 5-point Lik-
ert scale (1 = Strongly disagree; 2 = Disagree; 3 = Indif-
ferent; 4 = Agree; 5 = Strongly Agree). All the scores were
summed up and converted to percentages. The average per-
centage perception score was then computed. Scores ≥60%
were graded as positive attitude towards infection control.
Data analysis was carried out using the Statistical Pack-
age for Social Sciences version 20. Descriptive statistics
was used for categorical variables that were expressed as
frequencies and percentages, while student’s t test was
used to compute the means and standard deviation of
continuous variables such as the age. The 5 Likert scales
were collapsed into 3 categories: Disagree (Scales 1,2),
Neutral (Scale 3), and Agree (Scales 3,4) for purpose of
the statistical analysis. Differences between categorical
variables were compared using the chi-square or Fisher’s
exact where indicated. The level of statistical significance
was set at P ≤ 0.05.
3 RESULTS
A total of 102 undergraduate clinical dental students
participated in the study. Males were slightly more (54.9%)
than females (45.1%). The mean age of the respondents
was 25.3 ± 2.4 years (range of 21–31 years). Majority (72.6%)
of the respondents were in their final year. Students in 9
out of the 12 dental schools participated in the study and
distribution is as follows: University of Lagos—35 (34.3%);
Obafemi Awolowo University—20 (19.6%); University
of Maiduguri—15 (14.7%); University of Nigeria Nsukka,
Enugu—12 (11.7%); University of Benin—6 (5.9%); Lagos
State University—5 (4.9%); University of Ibadan—5 (4.9%);
University of Medical Sciences, Ondo—2 (2%); and Bayero
University of Kano—2 (2%).
The mean overall knowledge score was 70.17 ± 10.0.
Overall, 51(50%) demonstrated adequate knowledge of
COVID-19. A significant proportion of the respondents
(78.4%) reported that they were up to date on the case def-
inition for COVID-19. Figure 1 shows the source of infor-
3
F I G U R E 1 Sources of information about COVID-19 among the
respondents in the present study
mation about COVID-19, which is the primary data col-
lected among the respondents during the present study.
Their source was mostly from the social media (99%), tele-
vision (81.4%), friends/family (45.1%), colleagues (42.2%),
and text message (39.2%), while the least source of infor-
mation came from academic training courses (8.8%). The
social media in this study included Twitter, Facebook,
Instagram, YouTube, etc., while the text message was the
short message service (SMS) through phone which was
utilized mainly by the Nigerian Center for Disease Con-
trol (NCDC) to disseminate COVID-19 related informa-
tion. Academic training courses on COVID-19 that were
freely organized by health organizations/bodies, locally
and internationally, were accessible to the respondents in
this study through different online platforms.
Table 1 shows the responses of the respondents to the
questions on COVID-19. Nearly 60% of the students cor-
rectly identified SARS-COV 2 virus as the cause of COVID-
19 while majority (95.1%) knew the average incubation
period as 1–14 days. Only 30.4% of the respondents knew
that mild to moderate symptoms occurred in 80% of those
infected with COVID-19, while 96.1% knew that asymp-
tomatic people could spread the coronavirus. Transmis-
sion routes of COVID-19 were reported as respiratory
droplets from coughing, sneezing, and talking (99%), and
airborne (52.9%). Some of the symptoms of COVID-19
known by the respondents included shortness of breath
(100%), cough (99%), fever (97.1%), loss of smell or taste
(49%), joint/muscle pain (44.1%), chills (42.2%) and diar-
rhea (25.5%).
The sample collection methods to diagnose COVID-19
was reported by 85.3% as real-time PCR with nasopharyn-
geal swab/sputum and 23.5% as real time PCR with endo-
tracheal aspirate. Only 16.7% of the respondents knew the
4 UMEIZUDIKE et al.

TA B L E 1 Responses to questions on the knowledge of COVID-19

Correct responses Incorrect responses
Questions N (%) N (%)
Cause of COVID-19 a virus called SARS-COV 2 61 (59.8) 41 (40.2)
Average incubation of COVID-19 1–14 days 97 (95.1) 5 (4.9)
Proportion of people infected with mild-moderate disease 80% 31 (30.4) 71 (69.6)
If asymptomatic people can spread the coronavirus Yes 98 (96.1) 4 (3.9)
Transmission routes of COVID-19
Respiratory droplets from coughing, sneezing, talking 101 (99.0) 1 (1.0)
Touching contaminated surfaces 97 (95.1) 5 (4.9)
Handshaking 74 (72.5) 28 (27.5)
Saliva 62 (60.8) 40 (39.2)
Airborne 54 (52.9) 48 (47.1)
Symptoms of COVD-19
Shortness of breath 102 (100.0) 0 (0.0)
Cough 101 (99.0) 1 (1.0)
Fever 99 (97.1) 3 (2.9)
Sore throat 81 (79.4) 21 (2.6)
Headache 66 (64.7) 36 (35.3)
Loss of smell or taste 50 (49.0) 52 (51.0)
Joint/muscle pain 45 (44.1) 57 (55.9)
Chills 43 (42.2) 59 (57.8)
Diarrhea 26 (25.5) 76 (74.5)
Sample collection methods of diagnosing COVID-19
Real-time PCR with nasopharyngeal swab/sputum 87 (85.3) 15 (14.7)
Real-time PCR with oropharyngeal swab/sputum 60 (58.8) 42 (41.2)
Real time PCR with endotracheal aspirate 29 (28.4) 73 (71.6)
Real time PCR with bronchoalveolar aspirate 24 (23.5) 78 (76.5)
Confirmed case definition for COVID-19
Laboratory confirmation of SARS-COV-2 virus 17 (16.7) 85 (83.3)
Treatments being investigated
Hydrochloroquine/chloroquine with azithromycin 79 (77.5) 23 (22.5)
Remdesivir 70 (68.6) 32 (31.4)
Ivermectin 6 (5.9) 96 (94.1)
Pluristem 2 (2.0) 100 (98.0)
Current availability of vaccine for COVID-19 88 (86.3) 14 (13.7)
People at higher risk of COVID-19
Healthcare workers 98 (96.1) 4 (3.9)
Elderly 95 (93.1) 7 (6.9)
Individual with underlying medical condition 98 (96.1) 4 (3.9)
Close relatives of COVID-19 patients 89 (87.3) 13 (12.7)
Caregivers of COVID-19 patients 84 (82.4) 18 (17.6)
Travelers 79 (77.5) 23 (22.5)
Smokers 59 (57.8) 43 (42.2)
Preventive strategies for COVID-19
Frequent use of alcohol-based hand rub/sanitizer 101 (99.0) 0 (0.0)
Avoid touching of eyes, nose, and mouth 101 (99.0) 0 (0.0)
Frequent washing of hand with soap and water 100 (98.0) 2 (2.0)
(Continues)
UMEIZUDIKE et al.
TA B L E 1 (Continued)
Questions
Wearing of personal protective equipment by health worker
Wearing of facemask by all patients in dental clinic
Routine cleaning and disinfecting of surfaces
Social or Physical distance
Practice proper respiratory hygiene
Placing confirmed or suspected patients in adequately ventilated
room
Minimum social distancing by WHO 1 m
F I G U R E 2 Overall attitude towards infection control practices
against COVID-19
confirmed case definition for COVID-19. Hydroxychloro-
quine/chloroquine with azithromycin (77.5%) followed by
remdesivir (68.6%) were the 2 most commonly known
treatment options being investigated for treating COVID-
19. Over 86% knew there was currently no available vaccine
for COVID-19 while healthcare workers (96.1%) and indi-
viduals with underlying medical conditions (96.1%) were
among those identified with a higher risk for COVID-19.
Preventive strategies for COVID-19 such as the frequent
use of alcohol-based hand rub/sanitizer were reported by
99% of the respondents. The minimum social distance of
1 meter advocated by the WHO was known by only 19.6%.
The average perception/attitude score was 85.6 ± 10.4.
Generally, most respondents (95.1%) had good percep-
tion/positive attitudes to infection control practices in
preventing the spread of COVID-19 in their clinics and
training schools (Figure 2). Table 2 shows their percep-
tion/attitude towards infection control. Their responses
5
Correct responses Incorrect responses
N (%) N (%)
100 (98.0) 2 (2.0)
99 (97.1) 3 (2.9
98 (96.1) 4 (3.9)
92 (90.2) 10 (9.8)
82 (80.4) 20 (19.6)
76 (74.5) 26 (25.5)
20 (19.6) 82 (80.4)
included the perception that the current standard of infec-
tion control measures in their dental schools were effec-
tive in preventing the spread of COVID-19 (24.5%). Majority
(95.1%) agreed that aerosol-generating procedures in den-
tistry carried a high risk of spreading COVID-19. Regarding
their attitude, 92.2% were willing to undergo an infection
control training in dentistry for COVID-19 while only 39.2%
were willing to personally procure extra personal protec-
tive equipment (PPE) for use in the dental clinic to prevent
the spread of COVID-19.
Table 3 shows the association between knowledge
of COVID-19 and sociodemographic characteristics, and
perception/attitude towards infection control practices
against COVID-19. Only the year of study was signifi-
cantly associated with the knowledge of COVID-19, as the
final-year students (58.1%) demonstrated more adequate
knowledge of COVID-19 than the penultimate-year stu-
dents (28.6%) (P = 0.008).
4 DISCUSSION
The rapid surge in the number of cases during the COVID-
19 pandemic has placed enormous strain on health care
systems and significantly impacted educational systems
globally, including dental training institutions in health
care settings of undergraduate dental students. There are
currently about 12 accredited dental schools in Nige-
ria. Prior to the COVID-19 pandemic, studies by Isiekwe
et al.14–16 among undergraduate dental students in Nige-
ria observed a lack of satisfaction with the quality of their
clinical training. This study sought to provide an overview
of dental students’ knowledge of COVID-19 and attitude
to infection control during this pandemic, which could
serve as guidelines in preparation for school resumption
and clinical training of the students.
The present study revealed that generally, only half
of the students had adequate COVID-19 related knowl-
edge. On the contrary, majority had a positive attitude
6 UMEIZUDIKE et al.

TA B L E 2 Perception/attitude towards infection control practices against COVID-19

Perception Disagree Neutral Agree

1. Current standard of infection control measures in dental school are effective in 52 (51.0) 25 (25.5) 25 (24.5)
preventing the spread of COVID-19
2. Aerosol generating procedures in dentistry carry a high risk of spreading 1 (1.0) 4 (3.9) 97 (95.1)
COVID-19
3. Proper hand washing before and after seeing each patient with soap and water is 2 (2.0) 3 (2.9) 97 (95.1)
very important in reducing the risk of COVID-19
4. All dental patients awaiting treatment should wear face covering/masks to 2 (2.0) 5 (4.9) 95 (93.1)
reduce the risk of transmitting COVID-19 to others
5. Changing face masks before and after treating each dental patient is more 3 (2.9) 5 (4.9) 94 (92.2)
protective than wearing the same mask for different patients
6. COVID-19 patients should be treated in a well-ventilated room or in a negative 5 (4.9) 12 (11.8) 85 (83.3)
pressure room
Attitude
7. Willing to undergo an infection control training in dentistry for COVID-19 5 (4.9) 3 (2.9) 94 (92.2)
8. Willing to personally procure extra PPE for use in the dental clinic to prevent the 42 (41.2) 30 (19.6) 40 (39.2)
spread of COVID-19
9. Wearing my gloves, face masks, goggles, and face shield while performing dental 12 (11.8) 14 (13.7) 76 (74.5)
procedure will adequately protect from contracting COVID-19 in the clinic
10. Wearing clinical scrubs with protective footwear without my personal clothes 12 (11.8) 10 (9.8) 80 (78.4)
when treating dental patients in the clinic gives better protection against
COVID-19 than wearing a clinical white coat on top of personal clothes
11. It is not advisable to wear the same cloth and footwear worn in the clinic to my 9 (8.8) 5 (4.9) 88 (86.3)
home or residence
12. It is necessary to change and wash my clinical white coat after daily use 3 (2.9) 5 (4.9) 94 (92.2)
13. If patient is sneezing or coughing persistently in the dental clinic, I will stop the 4 (3.9) 9 (8.8) 89 (87.3)
treatment and refer for COVID-19 test

towards infection control practices for preventing COVID-
19 within the dental clinics. Considering the fact that
majority (78.4%) of the students reported that they were up
to date on the confirmed case definition of COVID-19, it
was surprising to find only 16.7% of the respondents know-
ing the correct confirmed case definition, while only half
(50%) actually demonstrated overall good knowledge of
COVID-19. Our findings contrast with that of Yaling et al.,17
who reported a large proportion (82.3%) of university stu-
dents in China with good knowledge of COVID-19. A possi-
ble reason for the differences observed may be the fact that
fewer questions were used in that survey (5 questions)19
compared to our present survey which had many more
questions on COVID-19 (45 questions). It is thus most likely
that more information was required from the students in
the present study. Clinical dental students are expected to
possess an in-depth knowledge particularly due to their
access to the social media and television which were their
most frequent source of information in the present study.
The proportion of respondents with adequate knowledge
of the diagnosis, case definition, symptoms (like diarrhea,
joint/muscle pain, loss of smell, chills, headache), and at-
risk persons was observed to be low. This could be ascribed
to the novelty of the infection and the rapidly evolving
information concerning its epidemiology.
In this study 97% of the participants knew the correct
incubation period of COVID-19, which is contrary to the
findings of Khader et al., who reported that only 36.1% of
dentists in Jordan knew the correct incubation period.18
The news media in Nigeria has been flooded with regular
and continuous information from the NCDC (Nigerian
Centre for Disease Control) on the need for self-isolation
for a period of 14 days for people who developed specific
symptoms such as cough, fever, and breathing difficulties.
This would no doubt have increased the respondents’
awareness about these common symptoms, as the news
media was bombarded by campaigns to identify these
symptoms. Besides, the Jordanian study18 was conducted
at an earlier stage of the pandemic, which might have
accounted for the disparity in knowledge level of the
correct incubation period.
The majority of the dental students knew the early and
common features of the infection; this finding is crucial
as students should be able to easily identify a suspected
UMEIZUDIKE et al. 7

TA B L E 3 Association between knowledge and socio-demography, perception, and attitude towards infection control practices against
COVID-19
Socio- Inadequate Adequate
demography (n = 51) (n = 51) Total X2 P-value
Gender
Male 24 (42.9) 32 (57.1) 56 (54.9) 2.534 0.111
Female 27 (58.7) 19 (41.3) 46 (45.1)
Age group (years)
≤25 30 (52.6) 27 (47.4) 57 (55.9) 0.358 0.550
>25 21 (46.7) 24 (53.3) 45 (44.1)
Year of study
a
Penultimate 20 (71.4) 8 (28.6) 28 (24.5) 7.089 0.008
Final 31 (41.9) 43 (58.1) 74 (72.5)
Opinion on having up-to-date information on COVID-19 case definition
Yes 39 (48.8) 41 (51.2) 80 (78.4) 0.232 0.630
No 12 (54.5) 10 (45.5) 22 (21.6)
Formal training on infection control in dentistry
Yes 40 (47.1) 45 (52.9) 85 (83.3) 1.765 0.184
No 11 (64.7) 6 (35.5) 17 (16.7)
Regular training on infection control in dentistry
Yes 18 (50.0) 1 (50.0) 13 (12.7) 0.000 1.000
No 33 (50.0) 33 (50.0) 89 (87.3)
Formal training on infection control in dentistry for COVID-19
Yes 6 (46.2) 7 (53.8) 13 (12.7) 0.088 0.767
No 45 (50.6) 44 (49.4) 89 (87.3)
Perception/attitude to infection control practices against COVID-19
Positive 49 (50.5) 48 (49.5) 97 (95.1) 0.210 0.647
Negative 2 (40.0) 3 (60.0) 5 (4.9)
a
Statistically significant.

case and take the necessary immediate action and respond
appropriately. This was also the case in a Jordanian study
amongst dentists.18 The respondents in the present study
indicated good knowledge of the preventive strategies for
COVID-19. However, it was surprising to observe that the
minimum social/physical distance of 1 m (equivalent to
3 feet) recommended by the WHO19 was unknown by the
majority in the present study. A distance of at least 2 m
(about 2 arms’ length) between people has also been advo-
cated by other health authorities such as the U.S. Centers
for Disease Control and Prevention.20 It is important to
maintain the recommended distance to prevent a person
from inhaling droplets from someone with COVID-19 who
may be either asymptomatic or with symptoms of cough-
ing, sneezing, or speaking.
Knowledge of bronchoalveolar and endotracheal aspi-
rate for diagnosis was poor, however. This finding may
be attributed to the most frequently used methods in this
environment, which are oropharyngeal and nasopharyn-
geal swabs. Although nasopharyngeal swabs have typically
been used to confirm clinical diagnosis of COVID-19, a
Chinese study found bronchoalveolar fluid to have the
highest positivity (93%), followed by sputum (72%), nasal
swabs (63%), pharyngeal swabs (32%).21 The respondents’
knowledge of hydrochloroquine/azithromycin and rem-
disivir was particularly impressive compared to that of
pluristem and ivermectin. This may be due to the several
controversies that have been generated regarding the
effectiveness of these drugs, especially the antimalarial
drug chloroquine and its derivative hydroxychloroquine,
which the WHO is testing in some clinical (solidarity)
trials22 in which Nigeria is participating.
The higher knowledge demonstrated by the final-year
compared to the penultimate-year students could stem
from a greater urge to learn more about the coron-
avirus and a deeper concern, eagerness, and anticipation
amongst the final-year students to complete their clinical
procedures upon school resumption in order to write the
qualifying exams. It would therefore not be unexpected
by them to want to learn more about COVID-19. These
8 UMEIZUDIKE et al.
findings highlight the need to improve the knowledge span
of undergraduate clinical dental students about COVID-19
in order to mitigate its spread. This should be included in
the curriculum for dental students all over the world.
The greater percentage (83.3%) of the students claimed
to have had formal training on infection control while
only 12.7% have had formal training on infection control
in COVID-19. This finding is not farfetched, as the lock
down period might have prevented a more organized or
structured training/teaching. The majority of the students
(94.1%) in the present study had a good perception and pos-
itive attitude towards infection control practices, similar to
Yaling et al.’s findings in China, where 73.8% of their sub-
jects demonstrated positive attitudes.17 This is crucial, as
the current approach to COVID-19 is to control the routes
of infection and to conduct extensive infection prevention
and control (IPC) trainings with preventive measures to
lower the risk of transmission.18 Surprisingly, knowledge
did not influence the attitude of the students significantly
in this study.
However, it was noted that there was a lack of will
by most students to personally procure extra PPE to
prevent the spread of COVID-19, when they recommence
their clinical procedures. These materials are currently
scarce in the market and quite expensive too, and many
students may lack the funds to procure them. Besides,
there could be a notion that the school authorities are
to provide these items. Undergraduate dental education
in Nigeria is heavily subsidized by the government, with
almost all the dental schools located in either federal
or state government-owned universities. Thus, students
pay very minimal tuition, however, they are expected to
purchase most of the bench items required for training.
Furthermore, since the dental schools are dependent
on the government for most of their funding, they often
have restrictive finances due to limited funding from the
government. The provision of PPE by the dental school
may therefore be an additional financial burden; in this
context, without additional help from the government,
the dental schools may be constrained to ask the students
to procure their own PPE for training.
This underscores the critical need by stakeholders to
make appropriate PPE available for all undergraduate
clinical dental students to curtail the spread of COVID-19
particularly in resource restricted countries like Nigeria.
Government and all stakeholders in the health and educa-
tional sectors must cooperate to fight this deadly scourge
ravaging the whole world.
Majority of respondents (74.5%) agreed that wearing of
face masks, gloves, goggles, and face shields while per-
forming dental procedures will protect against COVID-
19. This observation is similar to effective infection
control advocated in China by Meng et al.12 It was
encouraging to note that most of the respondents recog-
nized that it was not advisable to wear the same cloth-
ing and footwear between the clinic and their hostels.
Approximately 61% of respondents strongly agreed that
wearing clinical scrubs with protective footwear with-
out their personal clothes when treating patients or
observing procedures in the clinic gives better protection
against COVID-19 than wearing clinical white coats on
top of their personal home clothing. This is in keeping
with standard infection protocols to avoid transmitting
infections.
The role of health care worker’s uniforms on the
horizontal transmission of pathogens in hospital settings
is controversial.23 In the study by Munoz-Price et al.,23
they found an association between the contamination of
providers’ hands and contamination of white coats, yet
they found no association between providers’ hands and
scrubs although this was mainly attributed to the reduced
frequency of laundering white coats than the scrubs. Prior
to the pandemic, white clinical coats were worn over per-
sonal clothes by clinical dental students in Nigeria during
school hours in the dental clinics. This may however not
be appropriate nor sufficient particularly with the highly
infectious nature of COVID-19 and might change when
the students resume to school. Advocating the wearing
of clinical scrubs and foot wears was supported by most
of the students in the present study. It would also equally
important to emphasize the frequent laundering of the
scrubs and foot wears. Of note is the significant proportion
of students supporting the need to change and wash their
clinical white coat after daily use.
Thus, it should be performed regularly and thoroughly
as it is a simple but effective measure that dissolves the
lipid coat surrounding the virus and kills or inactivates the
virus if the hands have been contaminated.12,19,24 In addi-
tion, in the present study, the perception held by many of
the students was to pause the dental treatment of patients
who start sneezing or coughing persistently in the dental
clinic and refer them for further screening and possibly a
COVID-19 test. This is in tandem with the WHO policy that
procedures which are likely to induce coughing should be
avoided (if possible) or performed cautiously.6,15,24
The importance of hand hygiene as one of the most
critical factors for reducing the risk of transmission of
COVID-19 has been previously reported.12,19 Thus, it
should be performed regularly and thoroughly as it is a
simple but effective measure that dissolves the lipid coat
surrounding the virus and kills or inactivates the virus if
the hands have been contaminated.12,19
Concerning the dental management of COVID-19
patients, 83.3% supported their treatment in a well-
ventilated room or in a negative pressure room. It is bet-
ter and advised to encourage good air flow whilst ensuring
UMEIZUDIKE et al.
physical distancing as much as possible. Meng et al.,12 pro-
posed that based on their experience, relevant guidelines,
and research, dentists are to take strict personal infec-
tion control measures that are effective and avoid or min-
imize operations that can produce droplets or aerosols.
Four-handed technique is considered beneficial for con-
trolling infection coupled with the use of saliva ejectors
with high volume to reduce the production of droplets and
aerosols.
4.1 Limitations
The nonprobability sampling method employed in the
study may be subject to selection bias as participants were
approached via online platforms. Environmental factors
in each dental school may have influenced the responses
recorded as each dental school has its own peculiari-
ties. Notwithstanding, this study has provided a national
perspective on the knowledge and attitudes/perceptions
of undergraduate clinical dental students towards the
COVID-19 pandemic and infection control practices in
Nigeria.
5 CONCLUSION
This study determined that only half of the undergraduate
clinical dental students had adequate general knowledge
of COVID-19. The students were not abreast of current
updates on COVID-19, particularly the confirmed case
definition and less common symptoms. The students
however had a good perception and positive attitude
towards infection control practices against COVID-19.
Our recommendations are that guidelines from reputable
health institutions/authorities on COVID-19 be reviewed
by the dental school authorities and included in the dental
school curricula. The government should also make more
PPE available for clinical dental students.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ORCID
Kehinde Adesola Umeizudike BDS, MPH, FMCDS https:
//orcid.org/0000-0003-4893-872X
REFERENCES
1. Lu H, Stratton CW, Tang YW. Outbreak of pneumonia of
unknown etiology in Wuhan, China: the mystery and the mir-
acle. J Med Virol. 2020;92(4):401-402.
9
2. Rothan HA, Byrareddy SN. The epidemiology and pathogene-
sis of coronavirus disease (COVID-19) outbreak. J Autoimmun.
2020;109:1024-1033.
3. Coronavirus disease (COVID-19) Situation Report 129. World
Health Organization web site. www.who.int/docs/default-
source/coronaviruse/situation-reports/20200528-covid-19-
sitrep-129.pdf?sfvrsn=5b154880_2. 2020. Accessed June 7, 2020.
4. Coronavirus disease (COVID-19) Situation Report 51. World
Health Organization web site. www.who.int/emergencies/
diseases/novel-coronavirus-2019. 2020. Accessed March 11,
2020.
5. Updates on Coronavirus disease (COVID-19). Nigeria Centre
for Disease Control web site. www.covid19.ncdc.gov.ng/. 2020.
Accessed August 19, 2020.
6. COVID-19 Guidance for Dentistry. California Department of
Public Health web site. https://www.cdph.ca.gov/Programs/
CID/DCDC/Pages/COVID-19/GuidanceforDentistry.aspx.
7. CDC Guidance for Providing Dental Care During COVID-
19.Centers for Disease Control and Prevention. https://www.
cdc.gov/oralhealth/infectioncontrol/st
8. COVID-19 latest guidance for Wales. General Dental Council
web site. https://www.gdc-uk.org/information-standards-
guidance/covid-19/covid-19-latest-information/covid-19-latest-
guidance-for-wales. Last updates September 8, 2020. Accessed
September 14, 2020.
9. NDA Recommendations On COVID-19 Protocol for Dental Clin-
ics. Nigerian Dental Association web site. https://nigdentalasso.
org/about-us/. Accessed April 21, 2020.
10. Xu J, Li Y, Gan F, Du Y, Yao Y. Salivary glands: potential
reservoirs for COVID-19 asymptomatic infection. J Dent Res.
2020;99(8):989.
11. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and
surface stability of SARS-CoV-2 as compared with SARS-CoV-1.
N Engl J Med. 2020;382(16):1564-1567.
12. Meng L, Hua F, Bian Z. Coronavirus disease 2019 (COVID-19):
emerging and future challenges for dental and oral medicine. J
Dent Res. 2020;99(5):481-487.
13. Brondani M, Donnelly L. COVID-19 pandemic: students’ per-
spectives on dental geriatric care and education. J Dent Educ.
2020:1-8.
14. Isiekwe GI, Umeizudike KA, Abah AA, Fadeju AD. Nigerian
dental students’ perspectives about their clinical education. Uni-
lag J Dent Sci. 2019;3(1):3-7.
15. Isiekwe GI, Umeizudike KA, Abah AA, Fadeju AD. Under-
graduate dental education in Nigeria: perceptions of dental
students and recent dental graduates. Odontostomatol Trop.
2016;39(154):15-23.
16. Isiekwe GI, Umeizudike KA, Abah AA, Olatosi OO. Perception
of dental students and recent graduates of a Nigerian Dental
School on the quality of undergraduate training received. Uni-
lag J Med Sci Technol. 2015;3(1):34-44.
17. Yaling P, Chenchen P, Yan Z, et al. Knowledge, attitude and
practice associated with COVID-19 among university students:
a cross-sectional survey in China. BMC Public Health. In review.
18. Khader Y, Al Nsour M, Al-Batayneh OB, et al. Dentists’ aware-
ness, perception, and attitude regarding COVID-19 and infection
control: cross-sectional study among Jordanian Dentists. JMIR
Public Health Surveill. 2020;6(2):1e18798.
10
19. Health Topics: Coronavirus [Internet]. World Health Orga-
nization (WHO) web site. https://www.who.int/health-topics/
coronavirus#tab=tab_1 2020. Accessed June 2, 2020.
20. Coronavirus Disease 2019 (COVID-19) Social Distancing, Quar-
antine, and Isolation. Centers for Disease Control and Preven-
tion web site. www.cdc.gov/coronavirus/2019-ncov/prevent-
getting-sick/social-distancing.html. 2020. Accessed May 28,
2020.
21. Wang W, Xu Y, Gao R, et al. Detection of SARS-CoV-2 in differ-
ent types of clinical specimens. JAMA. 2020;323(18):1843-1844.
22. Effectiveness of use of chloroquine/ hydroxychloroquine in
COVID-19 case management. 2020. World Health Organi-
zation web site. www.apps.who.int/iris/handle/10665/332261.
2020. Accessed May 22, 2020.
23. Munoz-Price L, Arheart K, Lubarsky D, et al. Differen-
tial laundering practices of white coats and scrubs among
UMEIZUDIKE et al.
health care professionals. Am J Infect Control. 2013;41(6):565-
567.
24. Coronavirus disease (COVID-19) Advice for public.
www.who.int/emergencies/diseases/novel-coronavirus-
2019/advice-for-public. World Health Organization web
site. Accessed June 3, 2020.
How to cite this article: Umeizudike KA,
Isiekwe IG, Fadeju AD, Akinboboye BO, Aladenika
ET. Nigerian undergraduate dental students’
knowledge, perception, and attitude to COVID-19
and infection control practices. J Dent Educ.
2020;1–10. https://doi.org/10.1002/jdd.12423